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SECTION 1 NATURE OF FILING(check all that apply) <br /> [U❑ ew home to MHODS El Adding or removing a co-owner ❑ Demolition(Date: <br /> sed home sale ❑ Recording as real property ❑ Converted to storage <br /> El Security interest change ❑ Removing from real property status ['Trip Permit <br /> ❑ Transfer by inheritance El Other(please note): <br /> SECTION 2 APPLICANT INFORMATION (please print) <br /> ❑Dealer/Seller ❑Lender ❑Escrow/Title Agent Q'OwnerBuyer El Legal Representative <br /> Name: a _ (-_ 9 (� 4 \ <br /> (first,middle,last) V\COrki liv '-�TJ\ `� , Phone:q Address: <br /> City: W t ci b -h State: ZIP: 91 cr1 1 <br /> Email: tA.K4 k 'r--LA..51`i.e: er- t I . <br /> SECTION 3 HOME INFORMAT(ON (information inbold is required), <br /> Home ID#: j 3it,4, O R No Home ID: El New Home ❑Out of state home ❑Leaving County Deed Records <br /> Manufacturer: < 4 d -� -�- <br /> Model: WA k:Ayto w Year: iq C� <br /> Serial Number(s) HUD Label Number(s)*Required if new home <br /> GVV 12, a\Wfl A <br /> #of Sections: Sq.footage: a l L ' <br /> 3 Bedrooms: 3 Bathrooms: <br /> Roofing type: Lo & Siding type: ��M�k Heating type: :! . � °e:, Cooling type: '4- <br /> Date of sale <br /> (If applicable). 2 Sale price: L.)© ,D 0 Includes land: ❑Yes 21 No <br /> SECTION 4 DEALER:INFORMATION (leave blank if'no dealer) • <br /> Name: <br /> (first,middle, last) License#: <br /> Address: <br /> City: State: ZIP: <br /> Email: Phone: <br /> I hereby declare this manufactured structure is free and clear of all mortgages,deeds of trust,security interests,and liens.I have the <br /> legal right to sell this manufactured structure or my interest in it. The information listed is true to the best of my knowledge and <br /> belief,and I understand it can be used as evidence in court and is subject to a penalty of perjury. <br /> Signature: Date: <br /> SECTION 5 HOME LOCATION <br /> Current Address: «7 S Co o 1-eAd <br /> City: c\,'Ltd f County: X D yl State: 0 e Zip: <br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility <br /> ❑This home is being moved to a new location Complete the section below <br /> New Address: ) c Li' C ( yl 12 d <br /> City: LA) OG L,(AIM County: Tylxviv tel State: 0 less Zip:q 7 —7 <br /> Park Name: (if applicable) ❑This is a dealer lot or storage facility <br /> Transporter Name:`tieA0 r TlC. r l Phone:503. <br /> Address: City: State: <br /> Email: <br /> Page 2 <br />